Detailed and careful documentation is crucial for all aspects of the scleral
lens patient’s medical care. A thorough medical and ocular history details the patient’s
past medical treatments, outcomes, and previous contact lens modalities. This
information serves as a platform to diagnose, monitor and initiate new management
strategies including scleral lenses. Proper documentation may also aid the patient with
government services and insurance reimbursement. Since scleral lens fitting is intricate
and complex, detailed observations assist the practitioner with changing parameters,
lens designs, and supplemental ocular management. Due to the progressive nature of
ocular conditions that require scleral lenses, photodocumentation of baseline findings,
topographies, OCT images, and careful notetaking aid practitioners in optimizing
management strategies. When communicating with the patients medical team, a careful
summary of ocular findings may also aid their medical decision making. Lastly,
appropriate documentation may be necessary in medical-legal circumstances.
Keywords: Documentation, consultation, patient, ocular history, medical history,
penetrating keratoplasty, anterior segment disease, treatment, visual acuity,
refraction, slit lamp, eyelids, cornea, conjunctiva, Stevens-Johnson syndrome
(SJS), graft vs host disease (GvHD), landing, toricity, debris, dispense, imaging.
